What is the treatment for acute cholecystitis?

Treatment of Acute Cholecystitis

Early laparoscopic cholecystectomy within 72 hours of diagnosis is the definitive treatment for acute cholecystitis, with an acceptable window extending to 7-10 days from symptom onset. 1, 2

Initial Medical Management

Before surgical intervention, stabilize the patient with:

• Intravenous fluid resuscitation for hydration 2
• Fasting status (NPO) 2
• Empirical antibiotic therapy initiated immediately 1, 2
• Analgesia as needed for pain control 1

Antibiotic Selection

For uncomplicated cholecystitis in stable, immunocompetent patients:

• First-line: Amoxicillin/clavulanate 2g/0.2g IV every 8 hours 2
• Alternatives: Ceftriaxone plus metronidazole, or ticarcillin/clavulanate 2

For complicated cholecystitis or critically ill/immunocompromised patients:

• First-line: Piperacillin/tazobactam 4g/0.5g IV every 6 hours (or 16g/2g continuous infusion) 2
• Alternatives: Ertapenem or tigecycline 2

Important caveat: Anaerobic coverage is not required unless a biliary-enteric anastomosis is present, and enterococcal coverage is not needed for community-acquired infections in immunocompetent patients 1

Definitive Surgical Management

Timing Algorithm

Optimal timing: Within 72 hours of diagnosis 2

• This represents the ideal window for early laparoscopic cholecystectomy
• Acceptable extension: Up to 7-10 days from symptom onset 1, 2

Benefits of early surgery over delayed approach:

• Shorter hospital stay and recovery time 1
• Lower hospital costs 1
• Fewer work days lost 1
• Greater patient satisfaction 1
• Reduced risk of recurrent gallstone-related complications 1
• Lower rate of major complications 1

Surgical Approach

Laparoscopic cholecystectomy is preferred over open surgery in all suitable candidates 1

Risk factors predicting conversion to open surgery:

• Age >65 years 1, 2
• Male gender 1
• Thickened gallbladder wall 1
• Diabetes mellitus 1
• Previous upper abdominal surgery 1

Critical point: Conversion to open surgery should not be viewed as failure but as a valid safety option when necessary 1

Postoperative Antibiotic Management

For uncomplicated cholecystitis with complete source control:

• Discontinue antibiotics within 24 hours post-operatively 1, 2
• No further antibiotic therapy is required 1, 2

For complicated cholecystitis with adequate source control:

• Maximum duration: 4 days for immunocompetent patients 2
• Maximum duration: 7 days for immunocompromised or critically ill patients 2

Special Populations and Alternative Treatments

High-Risk or Critically Ill Patients

Immediate laparoscopic cholecystectomy is superior to percutaneous transhepatic gallbladder drainage (PTGBD) even in high-risk patients 1

However, gallbladder drainage (cholecystostomy) is recommended for patients who are:

• Not suitable surgical candidates 1
• Critically ill with multiple comorbidities 1
• Septic from acute cholecystitis 1

Mechanism: Percutaneous cholecystostomy converts a septic patient into a non-septic patient by decompressing infected bile or pus 1

Elderly Patients

Age >65 years is NOT a contraindication for laparoscopic cholecystectomy 1

• Elderly patients benefit from early cholecystectomy when fit for surgery 1
• Age is a risk factor for conversion to open surgery, not for withholding surgery 1

Conservative Management

Conservative management (fluids, analgesia, antibiotics alone) may be considered for mildly symptomatic acute cholecystitis 1

Critical caveat: Long-term outcomes are poor:

• 30% develop recurrent gallstone-related complications 1
• 60% eventually undergo cholecystectomy 1

If surgery is delayed, wait at least 6 weeks after clinical presentation before performing cholecystectomy 3

Concomitant Conditions

For choledocholithiasis or cholangitis:

• Endoscopic retrograde cholangiopancreatography (ERCP) for biliary decompression 2
• Consider magnetic resonance cholangiography (MRC) for common bile duct evaluation 2